Incidentolomas - Evaluation and
Management of Incidental Liver
Lesions
Patrick M. Horne, MSN, ARNP, FNP-BC
Assistant Director of Hepatology Clinical Research
Division of Gastroenterology, Hepatology and
Nutrition
University of Florida Health
Disclosures
• Financial relationships to disclose within
the past 12 months:
• Grant support with Bayer/Onyx
Objectives
• Discuss natural history of benign liver
lesions.
• Discuss Evaluation and management of
FNH, Hemangioma, Liver Cyst, Adenoma
Background
• Causes of focal liver lesions are diverse and
can range widely.
• Typically are clinically silent and detected
incidentally while undergoing evaluation for
unrelated symptoms.
• Understanding the clinical circumstances
surrounding the presence of liver lesions
aids in better diagnosis.
Differential diagnosis
• Common benign liver lesions include:
– Hepatic hemangioma
– Focal nodular hyperplasia (FNH)
– Hepatic adenoma
– Hepatic cyst
– Idiopathic noncirrhotic portal hypertension
• Focal nodular hyperplasia
– Regenerative nodules
Bonder A & Afdhal N. Clin. Liver Dis. 2012
Case 1
• 40 year old Caucasian female presents to
her PCP’s office intermittent nonspecific
abdominal pain and nausea.
• Physical exam negative but abdominal
ultrasound ordered which notes a possible
lesion.
• Follow up imaging obtained
Case 1
Persistent
enhancement
throughout
imaging phases
Hemangioma
• Most common benign hepatic tumor
• 60-80% diagnosed in people between the
ages of 30-50.
• Ratio of occurrence in women to men, 3:1.
– More common in young women
Choi BY & Nguyen MH. J Clin Gastroenterol.
2005
Hemangioma-Diagnosis
• On ultrasound appear well-defined,
lobulated, homogeneous hyperechoic mass.
• The accuracy of US is reported to be 70% to
80%.
• CT and/or MRI was best options
– With MRI having sensitivity and specificity
around 85-95%.
Descottes B et al. Surg. Endosc. 2003.
Unai O et al. Clin Imaging. 2002.
Hemangioma-Management
• Treatment is usually not indicated in the
setting of no symptoms with a firm
diagnosis and confirmed stability on
imaging at least 6 months apart.
– Lesions less than 5 cm
• Larger lesions may require closer
monitoring and if symptoms develop may
need to treatment.
Blecker E et al. Z. Gastroenterol. 2003
Hemangioma-Management
• Treatment options include
– Surgery
• Resection
– Hepatic irradiation or transarterial catheter
chemoembolization
Case 2
• 25 year old Hispanic female undergoing
work up for elevated liver function tests
(LFTs).
• Noted to have multiple liver lesions on
abdominal ultrasound, the largest
measuring 13 cm in diameter.
• Follow up imaging including CT and MRI
completed.
Case 2-Imaging
• CT scan
Case 2-Imaging
• MRI
Focal Nodular Hyperplasia (FNH)
• Second most common liver tumor
• Incidence is on the rise due to better
imaging.
• Can occur in both men and women
– 80-95% of cases seen in women, ratio 5:1
Bartolotta TV et al. La Radiologia Medica. 2013.
FNH-features
• Class findings include:
– Presence of a “central scar” on contrast
enhanced imaging
– Present in about 1/3 of patients
– Lesions typically become hyperdense during
arterial phase imaging.
• Due to arterial origin of the blood supply
– Isodense during portal venous phase
• Though central scar may be hyperdense
Bartolotta TV et al. La Radiologia Medica. 2013.
FNH-Diagnosis
• Sulfur colloid scanning
– Due to prevalence of Kupffer cells, 80% of FNHs
will show active uptake
FNH-Management
• Typically conservative.
• Typically stable lesions and do not change
over time
• No evidence to suggest malignant
transformation
• Enlargement and/or development in the
setting of OCP?
Case 3
• 30 year old Caucasian female presents with
chronic abdominal pain.
• Has been on oral contraception therapy for
5 years
• Otherwise healthy, no significant medical
history.
Case 3
MRI
Hepatic adenoma
• Uncommon lesions
• Mostly in young women (22-40)
• Commonly in the right lobe of the liver
Grazioli L. Radiographics. 2001
Hepatic adenoma
• Strong association with:
– Oral contraceptives and hormones
– Anabolic steroids
– Glycogen storage disease
• Less common association:
– Pregnancy
– Diabetes mellitus
Farges O. Gut. 2011
Hepatic adenoma
• Prognosis not well established
• There is an association with:
– Malignant transformation
– Spontaneous hemorrhage
– Rupture
Hepatic adenoma-Diagnosis
• Typically made clinically with imaging.
• Biopsy of the lesion is not indicated or
recommended due to risk of bleeding.
• Imaging techniques:
– US-limited
– CT and/or MRI
Hepatic adenoma-Diagnosis
• CT: Well demarcated and have low
attenuation or are isodense on noncontrast
imaging and show peripheral enhancement
early with centipedal flow during portal
venous.
• MRI: usually well demarcated and typically
hyperintense on T1. Enhancement on T2
images that enhance further with
gadolinium administration is highly
Grazioli L. Radiographics. 2001
suggestive.
Chung. KY AJR. 1995
Hepatic adenoma-Management
• Dependent on size of lesion and symptoms
• If asymptomatic and lesion is small (less
than 5 cm)
– Stop OCP if taking
– Can monitor with imaging and possibly AFP
• If symptomatic and/or lesion is large
(greater than 5 cm)
– Surgical resection is recommended.
– Liver transplantation rare
Dokmak S. et al. Gastroenterology.
2009
Case 4
• 60 year old female presents to a local ER
with severe abdominal pain with a palpable
mass on physical examination.
• No known history of liver disease or GI
symptoms
Case 4
Hepatic cyst-Differential
Hepatic cyst-Prevalence
• Dependent on origin
– Simple:
• More common in right lobe.
• More in women, ratio of 1.5:1.
• Distinction between simple and other types of cysts
is difficult to make but very important for
management.
– Huge cysts found often in women over age 50.
Hepatic cyst-Diagnosis
• Ultrasound:
– Good at distinguishing between simple and other
cystic lesions
• CT scan:
– Well demarcated lesion with no enhancement after
administration of IV contrast.
• MRI:
– No enhancement with contrast. T1-weighted
images the cyst shows a low signal, whereas a very
high intensity signal is shown on T2-weighted
images.
Simple cyst
Cystic
echinococcosis
Alveolar
Echinococcosis
Cystadenoma
And
cystadenocarino
ma
Border
Sharp and
smooth
Laminated
Irregular
Irregular
Shape
Spherical or oval
Round or oval
Irregular
Round or oval
Echo pattern
Anechoic
Anechoic or
atypical
Hyperechogenic
outer ring and
hypoechogenic
center
Hypoechogenic
with
hyperechogenic
septations
Appearance
No septa
multiseptated
multivesicular
Septated and/or
sold structures
Wall
Strong posterior
wall echoes
Posterior
acoustic feature
Relative
accentuation of
echoes
Lantinga MA. 2013. World
Journal of Gastro.
Wall
enhancement
Dorsal shadowing Doral shadowing
(calcified areas)
(calcified areas)
Hepatic cyst-Management
• Symptoms and type of cyst drive the
management
– Majority do not require intervention (if simple).
– Would consider monitoring large cysts over 4
cm with interval imaging.
– Minor and major surgical options available for
large cysts and/or symptoms
Hepatic cyst-Management
• Interventions:
– Needle aspiration (though associated with high
failure rate and rapid recurrence)
– Deroofing
– Liver resection
– If infectious, treat appropriately.
Yasawry MI. World J Gastroenterol.
2011
Conclusion
• Liver lesions are common and proper
diagnosis is important.
• A combination of medical history as well as
appropriate imaging is essential.
• Most liver lesions are benign but in certain
situations must be addressed or treated.
Thank you